Provider Demographics
NPI:1801865282
Name:KULYS, RUTA R (LCSW)
Entity type:Individual
Prefix:
First Name:RUTA
Middle Name:R
Last Name:KULYS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19642
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9642
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-2275
Practice Address - Street 1:901 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4833
Practice Address - Country:US
Practice Address - Phone:217-545-8000
Practice Address - Fax:217-545-2275
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490050341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL222014OtherTRICARE
ILF400100642Medicare PIN